Severe Hemorrhage : Damage Control Surgery Dirk YSEBAERT, MD PhD - - PowerPoint PPT Presentation

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Superior Health Council Expert Meeting "Severe bleeding: from basics to practice“

Brussels, 28/11/2013

Severe Hemorrhage : Damage Control Surgery

Dirk YSEBAERT, MD PhD Head of Department of Hepatobiliary, Transplantation and Endocrine Surgery Antwerp University Hospital Belgium

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HGR Expert Meeting 28/11/2013

Disclosure

• DY does not have any relevant disclosures for

the topic of this Expert Meeting

• The presentation of DY is not sponsored by any

company nor are any specific products or companies identified

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HGR Expert Meeting 28/11/2013

Overview: Damage Control Surgery

• Principles
• Lethal triad - Metabolic failure
• Practice :

– Damage control surgery – Organ-specific techniques – Critical care – Reoperation

• Conclusion

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HGR Expert Meeting 28/11/2013

Severe hemorrhage

• Exsanguinating haemorrhage accounts for 33-

40% of all trauma-associated deaths. – About half occur before the patient reaches the hospital.

• All civilian and military trauma systems face the

challenge of ensuring that bleeding patients receive timely and effective haemorrhage control.

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HGR Expert Meeting 28/11/2013

Damage control

• nly initial interventions necessary

to control hemorrhage and contamination to focus on reestablishing a survivable physiologic status. then continued resuscitation and aggressive correction of their coagulopathy, hypothermia, and acidosis in the ICU before returning to the OR for the definitive repair of their injuries.

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Damage Control Surgery (DCR)

ER OR ...........DEATH ER OR ICU OR ICU

DCR = rapid initial control of hemorrhage and contamination with packing and temporary closure, followed by resuscitation in the ICU, and subsequent reexploration and definitive repair

• nce normal physiology has been restored.

time

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HGR Expert Meeting 28/11/2013

Damage Control Resuscitation

= treatment strategy that targets the conditions that exacerbate hemorrhage in trauma patients

• Damage Control Surgery (DCS)
• Targetting the destructive forces of
• hypothermia
• acidosis
• coagulopathy
• (Evidence based)Transfusion ratios / hypertonic fluid solutions
• Permissive hypotension
• (rFVIIa / tranexamic acid / cryoprecipitate)

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Damage Control Resuscitation

Permissive hypotension Haemostatic resuscitation Damage Control Surgery

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HGR Expert Meeting 28/11/2013

DCR

Three Phases of Damage Control Surgery

• 1. A B C D Resuscitation

& Initial operation with hemostasis and packing 1bis Transport to interventional radiology suite for embolization

• f arterial hemorrhage that could not be controlled during the
• pen procedure, such as pelvic fracture or liver trauma involving

the arterial circulation.

• 2. Transport to the ICU to correct the conditions of hypothermia,

acidosis, and coagulopathy

• 3. Return to the OR for definitive repair of all temporized injuries

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HGR Expert Meeting 28/11/2013

Initial A B C D Resuscitation Breathing & Ventilation (1)

Severe life threatening condition

• Tension pneumothorax
• Massive hemothorax
• Open pneumothorax
• Flail chest

 Need emergency care

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HGR Expert Meeting 28/11/2013

Initial A B C D Resuscitation Breathing & Ventilation (2)

• 1. Tension pneumothorax

– Temporary : needle (no.14-16) at second intercostal space ,midclavicular

• ICD : fifth intercostal space ,midaxillary line
• 2. Massive hemothorax – ICD : fifth intercostal space ,midaxillary line

Indication for surgery – Bleed > 1500 cc on first ICD attempted – Continuous bleed > 200 cc/hr in 3-4 hrs

• hemodynamic unstable (caked hemothorax)

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HGR Expert Meeting 28/11/2013

Initial A B C D Resuscitation Shock (1)

Initial step in managing shock in the injured patient : Recognize its presence and clinical presence of inadequate tissue perfusion and oxygenation. Hemorrhage is the most common cause of shock in the injured patient. Second step : Identify the probable cause of the shock state.

External hemorrhage control : – Manual compression / Splint / Elastic bandage Internal hemorrhage: Identify major sources of occult blood loss :

• Thoracic
• Abdominal cavities
• Soft tissue surrounding major long bone fracture
• Retroperitoneal space from pelvic fracture

Combination

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HGR Expert Meeting 28/11/2013

Initial A B C D Resuscitation Shock (2)

Shock in traumatic patients DD non-hemorrhagic shock !!

• Cardiogenic shock
• Tension pneumothorax
• Neurogenic shock
• Hypovolemic shock
• Septic Shock

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HGR Expert Meeting 28/11/2013

Assessment of hemorrhagic shock

If unidentified source of bleeding:

• Clinical assessment of torso
• Pelvic ring stability !!!
• association with intra-abdominal injury (75%)
• in polytrauma: 25 % incidence of pelvic fractures
• FAST and/or CT in shock room

 FAST positive + hemodynamic instability = DCS

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Focused Assessment with Sonography for Trauma (FAST)

Rapid Noninvasive Accurate Inexpensive Can be repeated Indications same as DPL Utility comprised by:

• besity

subcutaneous air previous surgery

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HGR Expert Meeting 28/11/2013

DCS :Principles

First 'damage control' procedure :

• control of hemorrhage
• prevention of contamination
• protection from further injury
• temporary closure

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HGR Expert Meeting 28/11/2013

Cross talk Surgeon – Emergency Specialist (1)

Permissive hypotension

• Keep the blood pressure low enough to avoid exsanguination while

maintaining perfusion of end organs.  If the pressure is raised before the surgeon is ready to check bleeding, blood that is sorely needed may be lost.

• Endpoint of resuscitation before definitive hemorrhage control was a

systolic pressure of 70 to 80 mmHg

• Trauma patients without definitive hemorrhage control should have a

limited increase in blood pressure until definitive surgical control of bleeding can be achieved.

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Technology

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HGR Expert Meeting 28/11/2013

Cross talk Surgeon – Emergency Specialist (2)

Hypothermia in severe hemorrhagic shock

• Large, well conducted retrospective studies have shown that a core

temperature of less than 35°C on admission is an independent predictor

• f mortality after major trauma
• Prevention of hypothermia is easier than reversal. Limit casualties’

exposure

• Warm all blood products and intravenous fluids before administration
• Use forced air warming devices, which are useful before and after

surgery but are less effective when the need for operative exposure restricts application to the limbs

• Employ carbon polymer heating mattresses, which are highly effective

and do not restrict surgical access

• (above normal) heating of the shock room and operating theatre

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HGR Expert Meeting 28/11/2013

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HGR Expert Meeting 28/11/2013

Damage Control Laparotomy (1)

• rapidly prepped from neck to knees with large abdominal packs soaked in

antiseptic skin preparation solution

• incision should be made from the xiphisternum to the pubis

may require extension into the right chest or as a median sternotomy

• immediate control is initially achieved with four quadrant

packing with multiple large abdominal packs.

• eventually aortic control at this stage,

at the diaphragmatic hiatus  clamp without isolation of aorta

• next step is to identify the main source of bleeding: careful inspection of the

four quadrants of the abdomen is necessary

• bleeding from the liver, spleen or kidney can generally be achieved by applying

pressure with several large abdominal packs

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HGR Expert Meeting 28/11/2013

Damage Control Laparotomy (2)

• controlling surgical bleeding: ligation, balloon catheter tamponade, or packing.
• splenic and renal injuries are treated with rapid resections
• non-bleeding pancreatic injuries are simply drained
• liver injuries are packed
• use of topical hemostatical agents
• hollow viscus perforations : prevention of contamination
• either a simple suture closure or rapid resection of the involved segment
• no anastomoses are performed, and ostomies are not matured
• bowel ends stapled

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Procoagulant supplementors Human-derived factors equine collagen patch with fibrinogen and thrombin (TachoSil) Liquid or aerosol: fibrin sealants (Tisseel, Evicel, Crosseal); gelatin–thrombin suspension (Floseal) Bovine-derived factors Gauze (FastAct); glue (BioGlue); sponge (TachoComb)

Mucoadhesives† Oxidised cellulose Gauze (Surgicel Fibrillar, Surgicel Nu-Knit) Gelatin Foam (Sugifoam, Gelfoam, Gelfilm) Factor concentrators Mineral zeolite Granules (QuikClot); mesh bags (QuikClot Sport Advanced Clotting Sponge); gauze (QuikClot Combat Gauze)

Topical Haemostatical Agents

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HGR Expert Meeting 28/11/2013

Damage Control Laparotomy (3)

• where necessary, mobilization and delivery of retroperitoneal structures

using several medial visceral rotation manoeuvers

• all intraabdominal and most retroperitoneal haematomas require exploration

and evacuation.

• non-expanding perirenal haematomas, retrohepatic haematomas or blunt

pelvic haematomas should not be explored and may be treated with abdominal packing --> subsequent angiographic embolization may be required

R L

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HGR Expert Meeting 28/11/2013

Damage Control Laparotomy (4)

Scheduled reoperation

• removal of clots and abdominal packs
• complete inspection of the abdomen to detect missed injuries
• haemostasis
• restoration of intestinal integrity
• abdominal wound closure

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HGR Expert Meeting 28/11/2013

Damage Control Laparotomy (5)

Completion of the procedure :

• temporarily closed using an improvised plastic bag (“Bogota bag”)
• ev. commercially available topical

negative pressure dressing

• facilitates observation of volume

and nature of drainage

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HGR Expert Meeting 28/11/2013

Evidence ?

• No randomised trial has ever evaluated the concept of DCS
• Retrospective reviews indicate improval of survival, especially in

penetrating injuries (Rotondo 1993, Carillo 1998,....)

• DCS nevertheless generally accepted, but only as part of DCR

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HGR Expert Meeting 28/11/2013

Task Force for Advanced Bleeding Care in Trauma

Recommendations for DCS :

1. Time elapsed between injury and operation should be minimized for patiens in need of urgent surgical bleeding control (1A)

• 2. Early FAST for detection of fluid with suspected torso trauma (1B)
• 3. Patients with positive FAST and hemodynamic instability should

undergo urgent surgery (1C)

• 4. Patients with pelvic ring disruption in hemorrhagic shock should

undergo immediate pelvic ring closure and stabilisation (1B)

• 5. Patients with ongoing hemodynamic instability despite adequate

pelvic ring stabilisation receive early angiographic embolisation or surgical bleeding control, including packing (1B)

Spahn, Crit Care 2007 & 2013

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HGR Expert Meeting 28/11/2013

Task Force for Advanced Bleeding Care in Trauma

Recommendations for DCS :

• 6. Early bleeding control must be acheived by packing, direct surgical

bleeding control and the use of local hemostatic procedures. In the exssanguinating patient aortic cross-clamping may be employed as an adjunct to achieve bleeding control (1C)

• 7. Damage Controle Surgery should be employed in the severly injured

patient presenting deep hemorrhagic shock, sign of ongoin bleeding ad coagulopathy (1C)

Spahn, Crit Care 2007 & 2013

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HGR Expert Meeting 28/11/2013

Logistic of trauma care

• Emergency room with FAST & MSCT
• “Hybrid” operation theatre to allow damage control

surgery and angiographic embolisation

• Level I – level II Trauma Centers

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Case:

Male, young Gunshot wound from epigastrium to right dorsal flank Laceration SMA / Portal-SMV confluens / pancreatic head and inferior caval vein Trauma center 1: clamping SMA / PV-SMV / packing Trauma center 2: veno-venous bypass / repair SMA / jugular vein graft interposition PV / Whipple

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Case:

Female 22 y Tennisball epigastrium Shatterd liver DCS + packing in trauma center 1 Transport trauma center 2 Hepatectomy and portocaval shunt Liver transplantation within 24 u

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HGR Expert Meeting 28/11/2013

Unanswered questions in DCS

• Which patients would benefit the most from haemostatic resuscitation, and

how should these patients be identified at the outset of resuscitation?

• Which patients will benefit from permissive hypotension?
• What are the precise indications for recombinant factor VIIa, tranexamic

acid, and cryoprecipitate?

• Would better resuscitation reduce the need for damage control surgery and

allow more patients to undergo primary definitive repair?

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HGR Expert Meeting 28/11/2013

Summary (1)

• Damage control surgery is adopted for severely injured patients,

in which the initial operation is abbreviated after control of bleeding and contamination to allow ongoing resuscitation in the ICU.

• Trauma resuscitation must address all three components of the

“lethal triad” of hemorraghic shock: coagulopathy, metabolic acidosis and hypothermia

• Damage control resuscitation integrates permissive hypotension,

haemostatic resuscitation, and damage control surgery

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HGR Expert Meeting 28/11/2013

Summary (2)

• Damage control surgery is a surgical strategy aimed at restoring

normal physiology rather than anatomical integrity; however, this component of damage control resuscitation should not be applied in isolation

• Damage control surgery starts in the ER, continues through the

OR and ICU until resuscitation is complete

• Topical haemostatic agents and interventional radiology are

nowadays useful adjuncts to surgical control of bleeding.

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